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Our Wicked Problem

I thought I’d put down on paper some of the rationale behind the Test Bed project. In broad terms Brighton and Hove City Council were interested in ideas to improve and promote self-management strategies of long-term conditions (LTCs) and this resonated with the University of Brighton’s interest in Digital Health, hence a collaboration was born. So why is it that we’re all focused on this wide-reaching topic? To answer this, I’ve taken inspiration from a recent assignment I completed for the Darzi programme on Co-Production.

Since the UK was introduced to the idea of the ‘Welfare State’ by Sir William Beveridge in 1942 we have come some way in battling his so called ‘Five Giants.’

Arguably we have made great leaps forward in tackling many of these social injustices: maternal and infant mortality at an all-time low, eradication of infectious diseases that plagued previous generations, high rates of literacy and employment, with a rise in our general standards of living. In doing so however we have become a victim of our own success, none more so than in the field of health and social care. We have an ageing population with complex care needs and the problem has been compounded by the ever-increasing wealth inequality which our welfare state has been unable to tackle. There are 15 million people in England living with a LTC; according to The Kings Fund, those in the poorest social class have a 60% higher prevalence of these conditions and disease also affects them with 30% greater severity. Whilst we have channelled our efforts into creating a world leading health service, pushing the boundaries of science ever further, most of the low hanging fruit has been plucked. We are now in the territory of marginal gains and diminishing returns within the health service: the UK health budget almost doubled between 2000 and 2010 for only modest improvements in outcome. Health spend continues to rise at exponential levels. We aren’t alone in this, as we can see below the USA is a few leagues ahead but this appears to be an issue affecting many developed nations.

Though the current model of health care may well be effective in acute, emergency and specialist care it is not in these domains that the majority of health expenditure is occurring: from the DoH’s own figures, £7 out of every £10 is spent on the management of LTCs. We seem to be using a 20th century system to tackle 21st century problems such as LTC, mental health, addiction and preventative medicine. Sir William Beveridge would be rolling in his grave were he to discover just how much is now being spent on health and social care: when he first envisioned his Welfare State he assumed that this upfront investment would reap its rewards in years to come, he had in fact expected the costs of the Welfare state to decrease as citizens became better educated, more affluent, well housed and healthier. The reasons this hasn’t happened are multi-fold but we can certainly apportion a fair amount of it to social inequity. Coming back to Health and Social care specifically, what is it that we’ve doing wrong?

Someone once described the NHS to me as the National Illness Service, the place you go to recover from illness, not to be healthy. Being healthy often starts a long time before any of us will ever have dealings with the NHS. It starts at home, at schools and within our communities. Broadly speaking these arenas for health would fall under the remit of Public Health England and how much of our health and social care budget is set aside for this? Worryingly very little and even less going into the future, which seems rather odd given that it’s a core theme of the Five Year Forward View but ho-hum, I’m not in charge. Our friends north of the border are far more insightful in this respect with closer ties between NHS Scotland and the Education system and have the legislation to back it. So, in the absence of support centrally for health promotion and disease prevention and current services not incentivised financially for such measures (let’s be clear, QOFs have had mixed results), it seems as though we’re putting the problem firmly back in the hands of individuals. It therefore feels natural that we should turn to the tools of the 21st century: personal computers, smart phones, social media to see what role they can play in helping tackle these problems. Whether we like it or not they are playing an increasing role in Health and Care and unless we get on board, it’ll end up a lawless land with citizens who pick up the costs and the risks as they try to navigate this tricky landscape alone. It was against this backdrop that our collaboration began, let’s hope we can make some headway in untangling this wicked problem.